2007 EMA Advanced Emergency & Acute Care Medicine Conference Atlantic City, NJ September 24, 2007

Edward P. Sloan, MD, MPH, FACEP

ED Neurological ED Neurological Emergencies Patients’ Emergencies Patients’

Neuroresuscitation Update:Neuroresuscitation Update: Coma, CNS Infection, TBI, & Coma, CNS Infection, TBI, & Hypothermic ResuscitationHypothermic Resuscitation


2007 EMA Advanced Emergency & Acute Care Medicine Conference

Atlantic City, NJAtlantic City, NJ

September 24, 2007September 24, 2007


Edward P. Sloan, MD, MPH FACEP

Professor

Department of Emergency MedicineUniversity of Illinois College of Medicine

Chicago, IL


Attending PhysicianEmergency Medicine

University of Illinois HospitalOur Lady of the Resurrection Hospital

Chicago, IL


DisclosuresDisclosures• FERNE Chairman and PresidentFERNE Chairman and President

• No individual financial disclosuresNo individual financial disclosures


Global ObjectivesGlobal Objectives

• Improve neurological emergencies Rx

• Know how to quickly evaluate patients

• Determine how to use empiric meds

• Provide evidence-based protocols

• Facilitate disposition, improve pt outcome

• Improve Emergency Medicine practice


Session ObjectivesSession Objectives

• Present relevant patient cases

• Discuss key clinical questions

• Review the procedures

• Restate driving principles

• Coma, suspected meningitis, SE

• Elevated ICP in TBI, INR in ICH, BP in AIS


MethodologyMethodology

• Identify key neurological emergencies

• Consider key clinical questions

• Search the medical literature

• Focus on evidence that supports practice

• Utilize www.guidelines.gov, www.acep.org

• Integrate into procedures

http://www.guidelines.gov/

http://www.acep.org/


A Guidelines PerspectiveA Guidelines Perspective• Key questions define clinical practice

• Robust literature, accessed via internet

• Actual practice standards are limited

• Most of what we do is well defined

• No need to greatly vary what we do best: empirically treat, stabilize, diagnose, and disposition pts during unstable ED period


A Perspective on ProceduresA Perspective on Procedures

• Critically ill ED patients

• True medical emergencies

• Limited time and resources

• A need to diagnose and act

• “Emergency physicians take a surgeon’s approach to medical emergencies.”

• We do procedures, we are good at them


Procedures & Clinical PracticeProcedures & Clinical Practice• Guidelines, pathways, protocols

• Procedures

• Translate research into clinical practice

• Specific, quantifiable

• Documented via medical record

• Viewed favorably in retrospect

• Lead to consistency, improved pt outcome


A Clinical Case:A Clinical Case:The Comatose PatientThe Comatose Patient


Patient Clinical HistoryPatient Clinical History

• 46 yo male

• EMS to ED

• Unresponsive

• Unable to be intubated in the field


ED PresentationED Presentation

• Responds to painful stimuli only

• GCS = 5

• No apparent trauma


Key Clinical QuestionsKey Clinical Questions

• Can you manage the comatose patient?

• Can you conduct a useful neuro exam?

• Can you determine the coma etiology?

• Do you know any useful mnemonics?


Empiric Comatose Patient Empiric Comatose Patient Therapies: Therapies:

The ProcedureThe Procedure


Empiric TherapyEmpiric Therapy

• Control the airway, ventilate




• Do a bedside glucose determination– Provide D50 for hypoglycemia

– Avoid hyperglycemia




• Do a bedside glucose determination– Provide D50 for hypoglycemia

– Avoid hyperglycemia

• Detect hypoperfusion (Decreased CPP) – CPP = MAP – ICP (MAP > 90 mmHg key)

– NS fluid boluses up to 500 cc each



• Assess for narcotic overdose– Nalaxone 2 mg IV or sublingual

– Be prepared to restrain patient



• Assess for narcotic overdose– Nalaxone 2 mg IV or sublingual

– Be prepared to restrain patient

• Assess for benzodiazepine overdose– Flumazenil 0.2 mg IVP x 5 (max dose 1 mg)

– If acute ingestion, initial dose OK, no seizure



• Assess for narcotic overdose– Nalaxone 2 mg IV or sublingual– Be prepared to restrain patient

• Assess for benzodiazepine overdose– Flumazenil 0.2 mg IVP x 5 (max dose 1 mg)– If acute ingestion, initial dose OK, no

seizure

• Examine for likely EtOH abuse – Thiamine 100 mg IVP or to IVF


Empiric Therapies: PrinciplesEmpiric Therapies: Principles• Airway management:

– Nasal or oral airway, ventilate, prepare for RSI

• Oxygen therapy• Obtain an accucheck, administer glucose• Fluid bolus for hypotension• Naloxone if evidence of narcotic use/abuse• Judicious flumazenil use for benzo abuse• Thiamine in alcohol abuse


Coma Patient Evaluation: Coma Patient Evaluation: The ProcedureThe Procedure


Coma Evaluation ProcedureComa Evaluation Procedure

• Assess the pt’s overall mental status


Mental Status DescriptionMental Status Description

• AVPU– Alert– Responds to verbal stimuli– Responds to painful stimuli only– Unresponsive

• Start with this description. It sets the tome for the complete presentation to consultants.




• Assess the ABCs (trauma)– Airway & gag reflex

– Breathing pattern and sufficiency

– Circulation adequacy and hypotension




• Assess the ABCs (trauma) – Airway & gag reflex



• Assess the skin, breath (toxidromes)




• Assess the ABCs– Airway & gag reflex



• Assess the skin, breath (toxidromes)

• Detect posturing following stimulation


Decorticate posturing in comatose patient

Lesion above the red nucleus

Lower limbs extend, upper limbs flex following stimulus

Activity in the brainstem flexor center, the red nucleus


Decerebrate posturing in comatose patient

Upper and lower limbs extend following stimulus (pain, startle,or auditory)

Normal inhibition by cortex on the extensor facilitation part ofret form is missing, so extensors hyperactive

Lat vest nuclei involved, ablate and extensor posturing reduced


Clinical Value of Decorticate & Decerebrate Posturing

Decorticate posturing (flexion) indicates a higher level of brainstem function (a good thing) than decerebrate (extension) posturing; therefore:

Comatose patients who go from decerebrate to decorticate (ascending progression of impaired area) havea better prognosis than those that go from decorticate todecerebrate (descending progression of impaired area).

Descending impairment will be uniformly fatal if medullary respiratory and cardiovascular centers are damaged



• Calculate the Glasgow Coma Scale score– Eye Opening (4), Verbal (5), Motor (6)

– 13-15 Mild AMS, 4-8 Coma, 3 Vegetative



• Calculate the Glasgow Coma Scale score– Eye Opening (4), Verbal (5), Motor (6)

– 13-15 Mild AMS, 4-8 Coma, 3 Vegetative

• Detect abnormal reflexes– Corneal reflex

– Babinski (Chadduck)



• Examine the pupils– Size and equality

– Light reactivity, consensual response

• Differentiate anisocoria from a true “blown pupil” and herniation

• Note that blown pupils do not occur in awake and responsive patients



• Examine the pupils– Size and equality

– Light reactivity, consensual response

• Perform the Doll’s eye maneuver


Doll’s Eye ManeuverDoll’s Eye Maneuver

• Oculocephalic reflex

• Caution with suspected c-spine injury

• Eyes should continue to face to ceiling

• If eyes follow movement of head to side, suspect brainstem involvement in coma



• Examine the pupils– Equality

– Light reactivity

• Perform the Doll’s eye maneuver

• Detect evidence of psychogenic coma– Protective reflex

– Propriety reflex



• Look for ongoing seizure activity



• Look for ongoing seizure activity

• Perform cold calorics


Cold Caloric ExaminationCold Caloric Examination

• Oculovestibular reflex• Normal for slow movement of eyes

towards, fast movement away from cold water into ear canal

• If eyes move towards cold water, intact brainstem despite coma

• If no eye movement towards stimulation, suspect brainstem injury



• Look for ongoing seizure activity• Perform cold calorics• Document checklist of coma findings

– Presence of coma, responsiveness, GCS– Vital signs, ABCs, empiric therapies– Exam findings checklist – Likely etiology– Likely location of lesion


Coma EtiologiesComa Etiologies

• T trauma, temperature

• I infections

• P psychiatric, porphyria

• S space-occupying lesion, stroke, SAH


Coma EtiologiesComa Etiologies

• A alcohol, other toxins

• E endocrine

• I insulin (DM complications)

• O oxygen deficiency, opiates

• U uremia, renal disorders


Coma Exam: PrinciplesComa Exam: Principles

• Many etiologies are apparent on exam

• Step-wise approach allows for detection

• Follows empiric therapies

• Precedes, directs neuroimaging

• Establishes baseline

• Mental status change then detectable


A Clinical Case:A Clinical Case: A Suspected Meningitis PatientA Suspected Meningitis Patient


Patient Clinical HistoryPatient Clinical History

• 63 yo female

• Weakness, fever, dehydration

• Mental status begins to deteriorate at home; 911 called

• EMS to ED



• Responds to verbal stimuli

• Delirious

• Fever of 102 degrees



• When do you give the ceftriaxone?• Do you have to give decadron? When?• When are vancomycin, ampicillin, and

acyclovir indicated?• IS there and optimal approach to

performing the lumbar puncture? • When might the LP be deferred? Why?



Lumbar Puncture Lumbar Puncture in Suspected in Suspected

Meningitis Patients: Meningitis Patients: The ProcedureThe Procedure


Lumbar PunctureLumbar Puncture

• Perform a complete neurological exam




• Evaluate clinically for increased ICP





• Obtain a CT prior to LP, assess ICP signs

Edward P. Sloan, MD, MPH, FACEPAndrew Perron, MD

Quadrigeminal cistern

Supracellar cistern


Quadrigeminal cistern

Sylvian cisterns



• Perform a systematic neuro exam



• Measure opening pressure when feasible– Measure in all LPs when feasible

– May lead to other diagnoses


Opening PressureOpening Pressure• Normal: 60-200 mm H2O (obese

patients up to 250mm H20• Elevated: Suggest increased ICP

(>250 mm H20)–Mass lesion (neoplasm, hemorrhage,

infection)–Overproduction of CSF–Defective Outflow Mechanics



• Perform a systematic neuro exam



• Measure opening pressure when feasible

• Consider sitting position, assess airway



• Perform a systematic neuro exam• Evaluate clinically for increased ICP• Obtain a CT prior to LP, assess ICP signs

• Measure opening pressure when feasible

• Consider sitting position, assess airway

• Caution with delirious patient



• Send CSF for interpretation:– Tube 1. Hematology: cell count, differential

– Tube 2. Microbiology: gram stain, cultures, antigen

testing

– Tube 3. Chemistry: glucose, protein

– Tube 4. Hematology: cell count, differential



• Send CSF for interpretation:– Tube 1. Hematology: cell count, differential

– Tube 2. Microbiology: gram stain, cultures

– Tube 3. Chemistry: glucose, protein

– Tube 4. Hematology: cell count, differential

• WBC, differential not subtle in bacterial meningitis and encephalitis??


CSF InterpretationCSF Interpretation

• Bacterial meningitis: – WBCs: Thousands+ WBCs, neutrophils– Frankly cloudy CSF fluid– Usually not CSF pleocytosis (inflammation)

• Viral meningitis, encephalitis:– CSF pleocytosis may be only finding– WBCs: lymphocytes, esp over time– CSF not frankly purulent


Traumatic TapTraumatic Tap

• Accidental trauma to a capillary, venule

• Increases both RBCs & WBCs in CSF

• If peripheral WBC normal subtract 1 WBC for every 500 RBC


XanthochromiaXanthochromia

• Rapid lysis of RBC in the CSF

• Results of breakdown of hemoglobin

• Begins to appear 2-4 hours after RBCs enter subarachnoid space

• If xanthochromia, not a traumatic tap

• Persists for 2-4 weeks


Calculating the Predicted Calculating the Predicted CSF WBC CountCSF WBC Count

Predicted CSF WBC count/microL =

CSF RBC count X (peripheral blood WBC count ÷ peripheral RBC count)


Validation of Prediction Validation of Prediction Calculation in AdultsCalculation in Adults

• 720 patients– CSF WBC count >10X predicted value

• Positive Predictive Value 48% for bacterial meningitis

– CSF WBC count < 10X predicted value• Negative Predictive Value 99% for bacterial

meningitis


Validation of Prediction Validation of Prediction Calculation in ChildrenCalculation in Children

• 92 children– CSF WBC count >10X predicted value

• 28/30 children (93%) bacterial meningitis

• 57 children– CSF WBC count < 10X predicted

• 100% prediction for the absence of bacterial meningitis


Lumbar Puncture: PrinciplesLumbar Puncture: Principles

• LP only if clinically feasible

• If increased ICP possible, careful CT review

• Sitting position, measure pressure fast flow

• Be careful in setting of delirium

• Treat with antibiotics first

• Bacterial meningitis interpretation useful


Antibiotic Therapy in Antibiotic Therapy in Suspected Meningitis Patients: Suspected Meningitis Patients:



Antibiotic Rx ProcedureAntibiotic Rx Procedure

• Administer 1-2 gr ceftriaxone stat



• Administer 1-2 gr ceftriaxone stat

• If bacterial meningitis is the likely diagnosis, administer:

–10 mg dexamethasone

–1 gr vancomycin

–1 gr ampicillin/sulbactam if age > 50 and Listeria suspected



• If viral encephalitis is likely, administer:– 1 gr acyclovir IVPB over 1 hour


Antibiotic Rx ProcedureAntibiotic Rx Procedure• If viral encephalitis is likely, administer:

– 1 gr acyclovir IVPB over 1 hour

• Treat close contacts: cipro 500 po x 1, rifampin 600 PO BID x 2 days, or

ceftriaxone 250 IM x 1


Anbx Rx: Driving PrinciplesAnbx Rx: Driving Principles• Administer ceftriaxone early, prior to CT• Consider meningitis risk carefully• High risk patients: vancomycin,

ampicillin/sulbactam, steroids• Give steroids when pt deemed high risk • Add acyclovir when encephalitis possible• LP only if clinically feasible• Be cautious for increased ICP


A Clinical Case:A Clinical Case:Elevated ICP Management Elevated ICP Management

in a TBI Patientin a TBI Patient


Patient Clinical HistoryPatient Clinical History• 22 yo male

• EMS to ED

• MVC, high speed

• Initially lucid, then deterioration in mental status

• GCS 9





• Can you manage the multiple trauma

• Can you detect and manage evidence of elevated ICP?

• Do you know neurosurgery indications?

• Do you know ICP monitoring indications?


Elevated ICP Therapy in Elevated ICP Therapy in TBI Patients: TBI Patients:



Elevated ICP Rx ProcedureElevated ICP Rx Procedure

• Evaluate globally all resuscitation needs


Global Resuscitation NeedsGlobal Resuscitation Needs

• Elevate head of bed

• Control airway

• Maintain SBP > 90 mm Hg

• Maintain oxygen sat > 90%




• Consider decadron if brain edema noted in non-traumatic causes of elevated ICP




• Consider decadron if brain edema noted

• Do not provide prophylactic osmotherapy






• Mannitol 20%, 100-200 cc (0.25-0.50 mg/kg) q 4 hr, not by continuous infusion







• Lasix 10 mg IVP q 8 hr







• Lasix 10 mg IVP q 8 hr

• Measure serum osmols BID, < 310 mOsm/L


Mannitol in Elevated ICPMannitol in Elevated ICP

• Indicated when clinical deterioration occurs (worsening mental status)

• Also useful when AMS present at baseline and cerebral edema noted

• In this instance not prophylactic per se



• Do not use prophylactic hyperventilation




• With clinical deterioration, achieve hypocarbia to pCO2 30-35 mm Hg (25-30)




• With clinical deterioration, achieve hypocarbia to pCO2 30-35 mm Hg (25-30)

• Raise ventilatory rate with constant tidal volume (rarely up to 12-14 ml/kg)




• With clinical deterioration, achieve hypocarbia to pCO2 30-35 mm Hg

• Raise ventilatory rate with constant tidal volume (rarely up to 12-14 ml/kg)

• Non-depolarizing paralytics, lidocaine to minimize ICP elevation bursts


Hyperventilation, Elevated ICPHyperventilation, Elevated ICP

• Tidal volume important

• 10 ml/kg in 80 kg pt: 800 cc tidal volume

• Most pts treated with smaller tidal volumes

• If pCO2 > 35, may need to both increase tidal volume and vent rate in order to maximize minute ventilation, oxygenation


Hyperventilation: TV ChangeHyperventilation: TV Change

• 80 kg person

• 700 cc tidal volume, rate 14

• Minute ventilation 9.8 L

• If pCO2 = 35, increase tidal volume to 800

• Minute ventilation increased to 11.2 L

• ~15% increase in tidal volume and minute ventilation


Hyperventilation: RR ChangeHyperventilation: RR Change

• 80 kg person

• 700 cc tidal volume, rate 14

• Minute ventilation 9.8 L

• If pCO2 = 35, increase AC rate to 16

• Minute ventilation increased to 11.2 L

• ~15% increase in tidal volume and minute ventilation


ICP Rx: Driving PrinciplesICP Rx: Driving Principles

• Know the clinical signs of elevated ICP

• Be able to detect elevated ICP on CT

• Consider decadron and mannitol use

• Consider prophylaxis with a phenytoin

• Be prepared to treat seizures and SE

• Know how to assess rostral-caudal deterioration (herniation)

Brian O’Neil, MD

Hypothermic Hypothermic Resuscitation in Patients Resuscitation in Patients

with CNS Injury Due to with CNS Injury Due to Cardiac Arrest Cardiac Arrest

Brian O’Neil, MD

Brian J. O’Neil, MD Professor

Department of Emergency MedicineWayne State University,

Research Director,William Beaumont Hospital

Royal Oak, MI

Brian O’Neil, MD

phospholipaseactivation

Free Arachidonate

ER Ca 2+ Depletion

REPERFUSION

EpinephrineATP

PKAactivation

PP2A

I 1activation

PP1inhibited

eIF2 kinase activation

eIF2 (P)

InhibitedProtein

SynthesisApoptosis

.O2-

Fe2+Lipid Peroxidation

Membrane Damage

InhibitedGrowth Factor

SignalingCHOP

Bad dephosphorylation,Bax, mitochondriarelease cytochrome c& caspase 9to APAF1

activecaspase 3

Cytosolic Ca 2+

ATP DepolarizationISCHEMIA

eIF4G & spectrindegradation

-calpainactivation calcineurin

activation NOSactivation

peroxynitrite

cAMP

AND REPERFUSION THAT LEAD TO NEURONAL DEATH

DEATH

MODEL OF MOLECULAR EVENTS DURING BRAIN ISCHEMIA

Brian O’Neil, MD

Historical ObservationsHistorical Observations• Not Dead till Warm and DeadNot Dead till Warm and Dead

• Cold patients would awaken in the MorgueCold patients would awaken in the Morgue

• Kids / Hockey Players- fall through ice, long Kids / Hockey Players- fall through ice, long rescue times, but good recoveryrescue times, but good recovery

• Hibernation: state of low oxygen, acidosis, Hibernation: state of low oxygen, acidosis, low energy supplylow energy supply

• Basic science animal research showed Basic science animal research showed promising resultspromising results

Brian O’Neil, MD

Hypothermia: Hypothermia: Potential MechanismsPotential Mechanisms

• 6% in metabolic rate per 1 C reduction in brain temperature

• CMR declined to 50% after brain cooling to 32 degrees C (CBF & CMR coupled)

• blocks release of excitatory amino acid• reduces early calcium rise• reduces calpain specific and cytoskeletal

damage

Brian O’Neil, MD

Clinical HypothermiaClinical Hypothermia

• Bernard et al (77 pts)• external cooling, ice bags, initiated by

EMS at ROSC • 33.5 C within two hours ROSC cooled

for 12 hours• Good outcome = 49% v 26%

Brian O’Neil, MD

Clinical HypothermiaClinical Hypothermia• The European group, 136 pts,

• VF arrest, comatose, stable hemodynamics • external cooling device,• 8 hrs = median time to target Temp (33 C)

• 14.4% did not reach target T° • Cooling for a mean of 24 hours• Good outcome = 55% v 39%

Brian O’Neil, MD

Hypothermia: Hypothermia: The Beaumont ExperienceThe Beaumont Experience

INCLUSION• Patients with witnessed out of hospital

cardiac arrest of presumed cardiac origin• any initial rhythm that had ACLS within 15

minutes• restoration of spontaneous circulation,

(ROSC) within 60 mins of collapse • able to obtain informed consent by

representative/family member were enrolled

Brian O’Neil, MD

Table 1: Baseline CharacteristicsTable 1: Baseline Characteristics

HYPOTHERMIA HYPOTHERMIA

PATIENTS PATIENTS NORMOTHERMIA NORMOTHERMIA

PATIENTSPATIENTS

DATESDATES 5/05-9/065/05-9/06 1/97-2/061/97-2/06

TOTAL PTSTOTAL PTS 2323 8080

AGE AVGAGE AVG 65.865.8 67.967.9

Bystand CPRBystand CPR 13 (56%)13 (56%) 45 (56%)45 (56%)

INITIALINITIAL RHYTHM RHYTHM

vfibvfib 14 (61%)14 (61%) 62 (78%)62 (78%)

peapea 4 (17%)4 (17%) 5 (6%)5 (6%)

asystoleasystole 5 (22%)5 (22%) 13 (16%)13 (16%)

Mean time till Mean time till ROSC ROSC 2121 1414

Brian O’Neil, MD

52%

33%

52%

28%

48%

72%

0%

10%

20%

30%

40%

50%

60%

70%

80%

DISCHARGED ALIVE CPC 1 or 2 CPC 3 or greater

MORTALITY AND NEUROLOGICAL OUTCOMES

HYPOTHERMIA PATIENTS NORMOTHERMIA PATIENTS

p = 0.033

Brian O’Neil, MD

Practical HypothermiaPractical Hypothermia• First thing you need are ChampionsFirst thing you need are Champions• Next get Buy In:Next get Buy In:

• ED, CCU, ICU, Nursing and AdministrationED, CCU, ICU, Nursing and Administration

• Sit down and hammer out a protocolSit down and hammer out a protocol• Educate StaffEducate Staff• Facilitate the first few patientsFacilitate the first few patients

Brian O’Neil, MD

Practical HypothermiaPractical Hypothermia• Initiation: Sooner the Better: Pre-hospital or in-hospitalInitiation: Sooner the Better: Pre-hospital or in-hospital

• Ice bags in Groin, Axilla and NeckIce bags in Groin, Axilla and Neck• Cold IV fluidsCold IV fluids• Regular cooling blanketRegular cooling blanket• Intravenous catheters / Gel PadsIntravenous catheters / Gel Pads

• More consistent temperature regulationMore consistent temperature regulation• Target 33.5 Target 33.5 C:C:

• Esophageal > bladder > rectal probesEsophageal > bladder > rectal probes• Bladder probes need urine outputBladder probes need urine output

• Watch for rapid drop, cooling is non-linear Watch for rapid drop, cooling is non-linear

Brian O’Neil, MD

Practical HypothermiaPractical Hypothermia• Paralyze / SedateParalyze / Sedate

• Ativan drip: added seizure controlAtivan drip: added seizure control• Watch for:Watch for:

• Low K+ and Mg ++Low K+ and Mg ++• High GlucoseHigh Glucose

• Stress dose insulin with bolusesStress dose insulin with boluses• BradycardiaBradycardia• Prolonged QTProlonged QT• BleedingBleeding• Pneumonia/ sepsisPneumonia/ sepsis

Brian O’Neil, MD

Practical HypothermiaPractical HypothermiaRe-warming:Re-warming:

• Not truly activeNot truly active• Decreased rate of coolingDecreased rate of cooling

• Beware of temperature overshootBeware of temperature overshoot• Stop re-warming around 35Stop re-warming around 35 C C

• Watch for:Watch for:• SeizuresSeizures• ArrhythmiasArrhythmias• FeversFevers

Brian O’Neil, MD

What the Future HoldsWhat the Future Holds• NMDA/ AMPA receptor antagonist and NMDA/ AMPA receptor antagonist and

• phase II trials have recently shown some efficacy in phase II trials have recently shown some efficacy in CHICHI

• Estradiols and ProgesteroneEstradiols and Progesterone• Hypothermia during resuscitationHypothermia during resuscitation• Cannabinoids::

• most potent antioxidants known, (dexanabinol)most potent antioxidants known, (dexanabinol)• Many receptor similarities to opioidsMany receptor similarities to opioids

• Also induces hypothermiaAlso induces hypothermia • Insulin and other growth factorsInsulin and other growth factors

Brian O’Neil, MD

What the Future HoldsWhat the Future HoldsOpioid receptor antagonistsOpioid receptor antagonists::

• -, DADLE, -, DADLE, opioid receptor, BRL-52537 opioid receptor, BRL-52537• proteins trigger hibernationproteins trigger hibernation

-opiate antagonists reverse hibernation-opiate antagonists reverse hibernation• pre-conditioning proteinpre-conditioning protein

- myocytes and neurons- myocytes and neurons• mechanisms: ATP-K+ channels, PKC, free radicalsmechanisms: ATP-K+ channels, PKC, free radicals

-increases ERK and bcl-2-increases ERK and bcl-2

Brian O’Neil, MD

ConclusionsConclusions• Post-ROSC Neurologic resuscitation:

• needs to improve

• Injury Mechanisms:•Complex, Multi-factoral•Silver Bullet Trials have Failed

• The Future Looks Bright• Therapeutic Hypothermia:

•Currently only proven therapy•Cheap, Easy, risk / benefit ratio is huge

Edward P. Sloan, MD, MPH

ConclusionsConclusions• Coma, CNS infection, TBI, and

hypothermic resuscitation after cardiac arrest all are important skills of the emergency care provider

• Treatment options are easy to identify • Procedures can be developed, followed• Pt outcomes can be optimized• EM clinical practice can be optimized

Thank you.Thank you.

[email protected]@ferne.org

[email protected]@uic.edu312 413 7490312 413 7490

ferne_ema_2007_neuroresus_cnspart2_sloan_092507_finalcd 04/19/23 18:21 Edward P. Sloan, MD, MPH, FACEP

http://www.ferne.org/

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2007 EMA Advanced Emergency & Acute Care Medicine Conference Atlantic City, NJ September 24, 2007